1 Credentialing, Licensing, and Reimbursement of the SUD Title Arial Bold – 34pt font Counseling Workforce Subtitle Arial – 25pt font Review of Policies and Practices Across the Nation Presenter’s Name Office or Department Name Presenter: Nilüfer İsvan, PhD Human Services Research Institute
Co-authors & Funding 2 Rachael Gerber, MPH 1 David Hughes, PhD 1 Kristin Battis, MPH 1 Judith G. Dey, PhD 2 Kristina D. West, MS, LLM 2 1 Human Services Research Institute Evan Anderson, MA 3 2 U.S. Department of Health and Human Services 3 Brandeis University Research funded by the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services
Presentation Outline 3 •Background & purpose •Overview of methodology •Review of licensing and credentialing policies •Review of billing eligibility & reimbursement •Conclusions and implications
Background 4 • US experiencing workforce shortage in SUD treatment field • SUD providers historically reimbursed by block grant funds • Expanded insurance coverage through recent health reforms • State-level system transformation • Integration and parity • However, workforce shortages and some barriers to insurance network participation remain
Purpose of the Study 5 • Identify state variation in policies regulating licensing and credentialing of SUD treatment providers • Identify state variation in billing eligibility and reimbursement across public & private insurance plans • Investigate barriers to and facilitators of increased treatment capacity and identify innovative strategies to address these challenges
Methodology Overview 6 1. Environmental scan • Literature review • Interviews with key informants 2. State review of licensing & credentialing policies 3. State review of billing eligibility & reimbursement 4. State case studies • California • New York • North Carolina • Texas
7 Review of licensing/credentialing policies
Defining the SUD workforce 8 • The SUD treatment workforce is broad, consisting of medical providers, behavioral health counselors, social workers, etc. • This study focuses on the SUD counseling workforce • Lack of standardized credentials • Wide variation in titles and credentials across states • Uneven availability of licensure across states • These factors likely impact billing/reimbursement eligibility
Career ladder for SUD counseling 9 SAMHSA’s Model Scopes of Practice and Career Ladder SAMHSA Category Title Minimum Degree Category Independent Clinical SUD Master’s; licensed to practice Category 4 Counselor/Supervisor independently Category 3 Clinical SUD Counselor Master’s; works under supervision Category 2 SUD Counselor Bachelor’s Category 1 Associate SUD Counselor Associate SUD Technician SUD Technician High school or equivalent + 2 additional categories: Peer Recovery Specialist Prevention Specialist
State-level review: Data and methods 10 • Search domain: Publicly available information on states’ licensing and certification boards websites • Classified all SUD credentials into one of SAMHSA’s five categories, plus peer recovery and prevention specialist • Reviewed data for comparability within and across categories and made adjustments; separated clinical supervisor category
States with at least one treatment credential, by 11 category 47 (92%) 46 (90%) 40 (78%) 37 (73%) Number of States 32 (63%) 22 (43%) 10 (20%) Category 4 Category 3 Category 2 Category 1 SUD Peer At least 1 Technician Recovery credential in each of the 6 categories
State variation in number of credentialing boards 12 Includes boards for SUD counselors and SUD prevention specialists 28 (55%) Number of States 19 (37%) 4 (8%) Single Board Two Boards Three Boards
States with licensure for SUD counseling 13 • 31 states (61%) have licensure • 20 states (39%) certification only
Minimum degree required to attain the highest 14 available SUD counseling credential in the state Master’s Bachelor’s Associate High School None
Minimum practice hours required to attain the highest 15 available SUD counseling credential in the state <1 year 1-2 years 3-4 years 5 years
Key issues related to credentialing 16 Low and inconsistent education requirements for practice Historical development Low salaries, low insurance outside of professional coverage, low clinical care reimbursement rates Lack of state licensure Lack of standard education statutes curricula Lack of national standard credentials, competency requirements, and reciprocity Low desirability as a career choice Low accessibility of information on credentialing and career advancement
Addressing credentialing-related issues 17 • Efforts to establish uniform standards for credentialing, career ladder, scopes of practice, and core competencies • Within-state consolidation of certification boards • Centralized information dissemination and technical assistance to providers • Degree programs linked to credentials, scholarships, loan repayment • State licensure statutes
18 Review of billing eligibility and reimbursement
State-level review: Data and methods 19 • Medicaid search domain: Publicly available documentation from provider/billing manuals, fee schedules, enrollment docs • Fee-for-service (FFS) Medicaid state plans • Commercial insurance search domain: UnitedHealth/Optum Provider Portal • Determine SUD counselors’ eligibility to: • Enroll in insurance plan as an “independent provider” type • Be reimbursed for 8 pre-defined billing codes
Billing codes 20 ASAM Level Billing Code (HCPCS) Billing Code Description 0.5 H0001 Alcohol and/or drug assessment 0.5 H0049 Alcohol and/or drug screening 0.5 H0050 Alcohol and/or drug services, brief intervention 1 H0004 Behavioral health counseling & therapy, 15 min 1 H0038 Self-help/peer services, per 15 min 1, 2.1 H0006 Alcohol and/or drug; case management 1, 2.1 H0007 Alcohol and/or drug; crisis intervention 2.1 H0015 Alcohol and/or drug; intensive outpatient 0.5 = early intervention 1 = outpatient services 2.1 = intensive outpatient services
Billing eligibility under Medicaid 21 • SUD counselors eligible in 11 states , all with licensure • Not eligible in 32 states; must work in an accredited facility • Could not determine eligibility in 8 states
Billing eligibility under Medicare 22 • Federal Medicare rules set eligible practitioner types • SUD counselors not eligible • Did not find evidence Medicare Advantage plans more flexible • Medicare Special Needs Plans (SNPs) • Dual Eligible Special Needs Plans (D-SNPs) • Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs) • These types of plans promising for expanded coverage and reimbursement options
Billing eligibility under Optum’s commercial plans 23 • SUD counselors eligible in 13 states , all with licensure • Optum requires a state license and ability to practice independently w/o supervision • Practitioner eligibility based on “geographic and special needs”
Alignment of licensure and billing eligibility 24 • Of 25 states with licensure and information on Medicaid billing eligibility, 11 (44%) allow SUD counselors independent status • SUD counselors eligible under Optum’s commercial plans in 42% of states with licensure • Licensure facilitates, but does not guarantee, billing eligibility • The 20 states without licensure are at a disadvantage for independent practice and billing
Key issues related to reimbursement 25 Low insurance coverage, low reimbursement rates Historical development outside of professional clinical care Low insurance billing Lack of state licensure eligibility statutes Lack of national standard credentials, competency requirements, and reciprocity Lack of pathways to independent practice Low desirability as a career choice Administrative burdens related to network participation and billing Low accessibility of information on credentialing and career advancement
Addressing billing-related issues 26 • Medicaid waivers, statewide system redesign • Health homes and bundled services • State licensure • Infrastructural resource pooling • State supports for joining insurance networks
27 Conclusions and Implications
28 Low and inconsistent education requirements for practice Historical development Low salaries, low insurance outside of professional coverage, low clinical care reimbursement rates Lack of state licensure Low insurance billing statutes Lack of national standard eligibility credentials, competency requirements, and reciprocity Lack of pathways to independent practice Lack of standard education curricula Low desirability as a career choice Administrative burdens Historical stigma and related to network criminalization of SUDs participation and billing Low accessibility of information on credentialing and career advancement
29 The interconnected nature of the barriers implies systemic responses that simultaneously address multiple factors through consensus building among federal, state, and local stakeholders.
30 Thank You!
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